VCU GI Consults

Schedule: 

• GI Inpatient consults is divided into two separate 2-week blocks. GI consult fellow A starts on consults for two weeks than switches to endoscopy for the remaining two weeks. GI consult fellow B does the opposite. 

Expectations of GI consult fellow:

• See all general GI consults, biliary, and advanced endoscopy consults at VCU between 7:00AM - 5PM (including consults placed during the previous night).

  • General GI consults - staffed with the GI consult attending (same as attending covering GI patients on DHS). Rounds are set up with the attending and typically occur after 11 AM (when DHS rounds are complete). 

  • Biliary/Advanced endoscopy consults: Cases are discussed with the advanced fellow, Dr. Vachhani or Dr. BouHaidar (typically in endoscopy unit) and plan is determined. The GI consult attending will later round on these patients with the fellow and consult note is sent to the GI consult attending. 

• Consults are received through HAIKU, therefore you MUST sign in to EPIC when you are on call. 

Travel cases: 

• • Who scopes: GI vs Hep vs DHS fellow 

    • For all new consults, and for patients not actively followed by the hepatology or DHS fellow, the GI consult fellow performs the procedure with the GI or Hepatology (based on hepatology attending preference) inpatient attending.

    • If the hepatology fellow is actively following a patient who later requires endoscopy, then he/she will perform the procedure with either the GI or Hepatology attending (ask hepatology attending first).

    • If a patient on DHS is transferred to the ICU for endoscopy, then the DHS fellow has the option of performing the procedure or offer the scope to the GI consult fellow.  

      • Caveat: the DHS fellow is strongly encouraged to participate in all PEG consults, regardless if bedside in the ICU or in the endoscopy suite. 

  • Who scopes: GI vs On-Call fellow

    • 0700-1700: Scoped by the day fellow and attending. 

    • 1700-0700: If a day consult is going to end up with endoscopy after 5PM due to timing/logistics, the consult fellow should evaluate the patient, obtain consent, write a pre-procedure H&P, and consult note. The endoscopy will be performed by the on-call fellow and attending.

  • Sequence of events for ICU/ ED cases: 

    • Text the attending as soon as you see the patient and discuss the case. If the attending agrees to scope, let the ICU team (and ICU nurse) know. 

    • Post the case: 

      • 0700-1700: 

        • 1) Place procedure order in EPIC and make sure to click "Yes" for the travel case option. 

        • 2) Provide pink slip to secretary 

        • 3) Talk to the endoscopy charge nurse (in person or call 804-828-8859) to post the case and ensure that the GI tech will set up the cart. 

      • 1700-0700 or on weekends: 

        • Page 6055 to notify techs and nurse (if unable to reach, contact Mary Freelander - contact info on tech on call page)

  • If anesthesia support is required: 

    • For any ICU scope at VCU requiring Anesthesia support (deep sedation), call the Anesthesia Coordinator at 804-663-4305. 

    • Post the case with the EPIC order "Case Request Operating Room" if planning to do case in the OR. 

  • Consent: 

    • Ensure your consent form is for both Endoscopy and Procedural Sedation,

    • Sedation paper forms are found in endoscopy or VCU intranet under clinical consent forms section from any computer and printer in the ICU.

    • Once the form is signed, hole punch it and place it physically in the patient's red chart so that it is not misplaced/lost. Can also ask unit secretary to scan into chart prior to the case starting. 

    • If the patient cannot consent (i.e. altered mental status), then obtain phone consent from next of kin along with phone confirmation from a witness signature (this can be another fellow, resident, or nurse)

Cases for the endoscopy suite: 

• All non-ICU cases should be posted in the endoscopy unit to be scoped during business hours with the approval of the service attending. 

  • While the GI consult fellow is welcome to assist in these procedures, this is not required to do so. 

  • Salient features of the case (i.e. anticoagulation, planned intervention, or special requests for biopsies) should be communicated to endoscopy team (best to do so by writing it down on the pink slip and discussing with charge RN and/or endoscopy attendings). 

  • GI consult fellow will need to obtain consent from family/POA for any patients who cannot consent (must be done before posting).

• Posting: 

• • All cases posted for endoscopy must have an endoscopy pink slip filled out and handed to the endoscopy secretary. 

  • If posting cases for the next day or Monday after weekend call: place in folder next to secretary's computer  

  • Please be cognizant of how many cases are being posted on one day and space out if appropriate

  • Please make sure updated Type & Screen on patients who are bleeding

  • Please fill out all sections of the pink slip 

Post-procedure etiquette:

• After endoscopy, the consult fellow MUST write a brief note that references the findings of the procedure, any further recommendations, and write "call if new questions or concerns" if signing off. You do not need to include an exam or full billable note. It is important to close the loop and demonstrate our final assessment and plan. Assign the note for review/sign to the consult attending.

Sign Outs:

• Day consult fellow: Must be updated daily in EPIC handoff under "Gastroenterology" (include pertinent information and outline tasks to do)

• Overnight fellow: Must provide in writing (email is ok) sign out about previous night's consults 

• Weekend fellow: Must update  EPIC handoff under "Gastroenterology" (include pertinent information and outline tasks to do)

In patient video capsule endoscopy expectations:

• Inpatient pill cams MUST be reviewed by the fellow who is arranging it (GI consult, DHS, etc). These should be either read on day of or after it is downloaded. Weekend call fellows are to read the pill cam as needed, but this should only be reserved if it has not been downloaded until Friday evening. It is not appropriate to wait for the Ambulatory fellow to read the following Wednesday.

• GI Fellow is responsible for requesting GI follow-up appointments.  To schedule please see page "Requesting Follow up CLICK HERE"

Transfer calls: 

• Discuss case with outside physician and whether appropriate for transfer. Even if DHS is full, if patient is appropriate for VCU, the patient can be admitted to medicine with GI or Hepatology consult. 

• Never "ACCEPT" a patient for transfer; tactfully say you believe that the person is a good candidate for transfer, but the requesting physician must call the Transfer Center at 804-828-2638 to discuss transfer approval as you do not have that power. Even if your attending "ACCEPTS" a transfer, the outside hospital must call the Transfer Center and MAA must be notified of acceptance to DHS. If you or your attending thinks the patient is best served on DHS then discuss with DHS fellow regarding space, and notify the MAA that you would like the person admitted to DHS.  

• Refrain from providing official recommendations for outside hospital calls asking about "phone consult." If this is an issue, fellow can discuss with the on-call attending.  You must call the outside hospital doctor back (you cannot just ignore their request), but you should say that our program has a policy of not providing specific medical recommendations due to medico-legal reasons regarding patients you have not evaluated and not in your facility. You can also offer the option of patient transfer if they need clinical assistance, but they must call Transfer Center at 828-2638 to discuss transfer approval.

Resource:

• How to be an effective GI consultant (CLICK HERE) created by Dr. Bickston